Maria Ramos

Lack of association between diagnostic and therapeutic delay and stage of colorectal cancer

BACKGROUND A recent review suggests that there is no association between diagnostic and therapeutic delays and survival in colorectal cancer patients. However, the effect of tumour stage on the relationship between delay and survival in CRC should be clarified. We review here the evidence on the relationship between diagnostic and therapeutic delays and stage in colorectal cancer. METHODS We conducted a systematic review of Medline, Embase, Cancerlit and the Cochrane Database of Systematic Reviews to identify publications published between 1965 and 2006 dealing with delay, stage and colorectal cancer. A meta-analysis was performed based on the estimation of the odds ratios (OR) and on a random effects model. RESULTS We identified 50 studies, representing 18,649 patients. Thirty studies were excluded due to excessively restricted samples (e.g. exclusion of patients with intestinal obstruction or who died 1-3 months after surgery) or because they studied only a portion of the delay. Of the 37 remaining studies, great variability was noted in connection with the type of classification used for disease stage and the type of measurement used for the delay. Meta-analysis was performed based on 17 studies that included 5209 patients. The combined OR was 0.98 (95% confidence interval (CI): 0.76-1.25), suggesting a lack of association between delay and disease stage. In four studies, cancers of the colon and rectum were dealt with separately, and a meta-analysis was performed using the data for colon cancer (1001 patients) and for rectal cancer (799 patients). In both cases, the combined ORs overlapped 1.0, and showed opposite associations when studied separately: 0.86 (95% CI: 0.63-1.19) for the colon (i.e. more delay is associated with the earlier stage at diagnosis) and 1.93 (95% CI: 0.89-4.219) for the rectum (i.e. less delay is associated with the earlier stage). CONCLUSIONS When colorectal cancers are taken as a whole, there appears to be no association between diagnostic delay and disease stage when diagnosis is made. However, when cancers of the colon and the rectum are studied separately, there may be an opposite association. More studies about this issue are needed with larger and unrestricted samples.

Factors related with symptom duration until diagnosis and treatment of symptomatic colorectal cancer

BackgroundColorectal cancer (CRC) survival depends mostly on stage at the time of diagnosis. However, symptom duration at diagnosis or treatment have also been considered as predictors of stage and survival. This study was designed to: 1) establish the distinct time-symptom duration intervals; 2) identify factors associated with symptom duration until diagnosis and treatment.MethodsThis is a cross-sectional study of all incident cases of symptomatic CRC during 2006–2009 (795 incident cases) in 5 Spanish regions. Data were obtained from patients’ interviews and reviews of primary care and hospital clinical records. Measurements: CRC symptoms, symptom perception, trust in the general practitioner (GP), primary care and hospital examinations/visits before diagnosis, type of referral and tumor characteristics at diagnosis. Symptom Diagnosis Interval (SDI) was calculated as time from first CRC symptoms to date of diagnosis. Symptom Treatment Interval (STI) was defined as time from first CRC symptoms until start of treatment. Nonparametric tests were used to compare SDI and STI according to different variables.ResultsSymptom to diagnosis interval for CRC was 128 days and symptom treatment interval was 155. No statistically significant differences were observed between colon and rectum cancers. Women experienced longer intervals than men. Symptom presentation such as vomiting or abdominal pain and the presence of obstruction led to shorter diagnostic or treatment intervals. Time elapsed was also shorter in those patients that perceived their first symptom/s as serious, disclosed it to their acquaintances, contacted emergencies services or had trust in their GPs. Primary care and hospital doctor examinations and investigations appeared to be related to time elapsed to diagnosis or treatment.ConclusionsResults show that gender, symptom perception and help-seeking behaviour are the main patient factors related to interval duration. Health service performance also has a very important role in symptom to diagnosis and treatment interval. If time to diagnosis is to be reduced, interventions and guidelines must be developed to ensure appropriate examination and diagnosis during both primary and hospital care.

La salud de los jóvenes

The objective of this article is to analyse different behaviours and opinions about health and health determinants of Spanish young people by age, sex, and place of residence. They have a broad concept of their health, tending to identify health as physical activity and healthy eating behaviours. Most of them (91%) declared enjoying good or very good health. Depending upon the age, sex, and place of residence 10 to 20% could have mental health problems. Young people consider illegal drugs as their main health problem. Boys have higher prevalence of overweight and obesity than girls. However, girls reported more often than boys that they perceived themselves as obese. Practice of sporting activities is influenced by family and friends. The proportion of young people that practice sport declines after the age of 15, both in boys and girls. Young people perceive cannabis consumption as normal, but remain ambivalent towards other illegal drugs and asked for more information about drugs. We found a high proportion of young people declaring that they not would try illegal drugs. In the urban settings, smoking is more common among girls than among boys, but the contrary happens in rural areas. Most of them know that smoking is harmful for health, and among those who are smokers, 20 to 40% declared that they want to stop smoking. They consider that health care services are useless for preventing health problems. It is necessary to improve behaviours involving safety, such as use of seat belts and helmets, mainly in rural areas. Young people associated traffic accidents with driving conditions rather than with identification of risk.

Effectiveness of intensive group and individual interventions for smoking cessation in primary health care settings: a randomized trial

ObjectivesPrimary: To compare the effectiveness of intensive group and individual interventions for smoking cessation in a primary health care setting; secondary: to identify the variables associated with smoking cessation.MethodsThree-pronged clinical trial with randomisation at the individual level. We performed the following: an intensive individual intervention (III), an intensive group intervention (IGI) and a minimal intervention (MI). Included in the study were smokers who were prepared to quit smoking. Excluded from the study were individuals aged less than 18 years or with severe mental conditions or terminal illnesses. The outcome measure was continued abstinence at 12 months confirmed through CO-oximetry (CO). The analysis was based on intention to treat.ResultsIn total, 287 smokers were recruited: 81 in the III, 111 in the IGI, and 95 in the MI. Continued abstinence at 12 months confirmed through CO was 7.4% in the III, 5.4% in the IGI, and 1% in the MI. No significant differences were noted between III and MI on the one hand, and between IGI and MI on the other [RR 7.04 (0.9-7.2) and RR 5.1 (0.6-41.9), respectively]. No differences were noted between IGI and III [RR 0.7 (0.2-2.2)]. In multivariate analysis, only overall visit length showed a statistically significant association with smoking cessation.ConclusionsThe effectiveness of intensive smoking interventions in this study was lower than expected. No statistically significant differences were found between the results of individual and group interventions.Trial registration numberISRCTN32323770

Adult community health-promoting interventions in primary health care: A systematic review

OBJECTIVE To examine evidence on the effectiveness of health-promoting community interventions carried out in primary health care. METHODS Systematic review of originals and systematic reviews of health-promoting community interventions with the participation of primary health care. A working definition of community activities was used in the inclusion criteria. Databases searched up to 2013: PUBMED, EMBASE, CINHAL, Web of SCIENCE, IBECS, IME, and PSICODOC. No restrictions on year of publication or design. Articles were reviewed by separate researchers to identify risks of bias. RESULTS Fifty-one articles published between 1966 and 2013 were included: 11 systematic reviews and 40 originals that described 39 community interventions. There is evidence on the effectiveness of community interventions in reducing cardiovascular risk factors, encouraging physical exercise, preventing falls and improving self-care among chronic patients compared with usual individual care. The effectiveness of some interventions increases when the community is involved in their development. Most assessments show positive results despite design limitations. CONCLUSIONS The community approach may be more effective than the individual in usual preventive interventions in primary care. There is a lack of evidence on many community interventions in primary care and further research is needed.

Age differences in presentation, diagnosis pathway and management of colorectal cancer

BACKGROUND The gap in survival between older and younger European cancer patients is getting wider. It is possible that cancer in the elderly is being managed or treated differently than in their younger counterparts. This study aims to explore age disparities with respect to the clinical characteristics of the tumour, diagnostic pathway and treatment of colorectal cancer patients. METHODS We conducted a multicenter cross sectional study in 5 Spanish regions. Consecutive incident cases of CRC were identified from pathology services. MEASUREMENTS From patient interviews, hospital and primary care clinical records, we collected data on symptoms, stage, doctors investigations, time duration to diagnosis/treatment, quality of care and treatment. RESULTS 777 symptomatic cases, 154 were older than 80 years. Stage was similar by age group. General symptoms were more frequent in the eldest and abdominal symptoms in the youngest. No differences were found regarding perception of symptom seriousness and symptom disclosure between age groups as no longer duration to diagnosis or treatment was observed in the oldest groups. In primary care, only ultrasound is more frequently ordered in those <65 years. Those >80 years had a significantly higher proportion of iron testing and abdominal XR requested in hospital. We observed a high resection rate independently of age but less adjuvant chemotherapy in Stage III colon cancer, and of radiotherapy in stage II and III rectal cancer as age increases. CONCLUSION There are no relevant age disparities in the CRC diagnosis process with similar stage, duration to diagnosis, investigations and surgery. However, further improvements have to be made with respect to adjuvant therapy.

Revisión documental de experiencias de actividad comunitaria en atención primaria de salud

OBJECTIVE Describe the community activities (CA) published or registered in health promotion networks in which Primary Health Care (PHC) has taken part. DESIGN Descriptive study, by documental review of experiences. DATA SOURCE articles, activities in exchange networks, presentations and funded projects. SELECTED EXPERIENCES: The AC included were those where PHC and the local community were involved in its inception, development and/or evaluation, but not solitary actions with no continuity. DATA EXTRACTION The following variables were collected: Source and year of the document; region; municipality; name and number of health centres involved; target population; objectives; involvement of the community, the health and the non-health sectors; theoretical perspective and evaluation methods. RESULTS A total of 472 activities were found that met criteria, involving 300 health centres in most of the autonomous regions. Of those, 71.8% were registered in networks, and 19.3% were registered in articles. The most frequent target populations were: the general population (22.2%), youth (18.2%) and parents (10.2%). More than half (58.2%) had one or more of the following objectives: to empower the community to choose healthy behaviours; transmit health information to the population, or encourage self-care. In 33.3% of the activities there were no other sectors involved besides Primary Care. Of the remainder, non-health sectors participated in 53.8%, civic bodies in 26.9%, and government administration in 24.2%. CONCLUSIONS Most of the CA are documented in networks and their presence is uneven by region. The involvement of sectors other than PHC in the activities identified is low.

Actitudes de las personas usuarias de atención primaria ante el cribado del cáncer colorrectal

OBJECTIVE To describe the cultural, social and gender features that determine attitudes to colorectal cancer screening in a target group of patients aged 50 to 69 years old in the primary health care setting. METHODS We performed a qualitative ethnographic study from a gender perspective. Participants consisted of men and women aged 50 to 69 years old in the Balearic Islands and Barcelona. Group discussion and a field diary were used. RESULTS The key element was diagnosis at an early stage. Until recently, cancer was considered an incurable disease but is currently perceived as a serious health problem that can be cured if diagnosed promptly. The participants requested more information on cancer and felt they were at risk, mainly because of their age. Men tended to pay attention to symptoms while women tended to ignore them. Attitudes to colorectal cancer screening were generally positive, even to colonoscopy. Some barriers to screening were identified in women, such as a fear of having cancer. CONCLUSIONS The opportunity for early diagnosis is the key element in promoting participation in a colorectal cancer screening program. Perceptions-and hence willingness to participate in screening-differ between men and women. Factors to be taken into account in the design of population-based colorectal cancer programs are health concerns in men and fear of a cancer diagnosis in women.

Observational study on factors related to health-promoting community activity development in primary care (frAC Project): a study protocol

Introduction According to Spanish health regulations, primary care professionals have the responsibility to carry out health-promoting community activities (CAs). However, in practice, their implementation is not as widespread as it should be. The aims of this study were to identify factors within the team, the community and the professionals that influence the development of these activities and to describe the community interventions in progress. Methods and analysis This study is an observational analytical retrospective study. The information will be collected from five Spanish regions: Catalonia, Madrid, the Balearic Islands, Navarra and Aragón. The authors will contact primary care teams (PCTs) and identify the CAs from the previous year. The research team will conduct a peer review whether the inclusion criteria are met. In the health centres where CAs are implemented, the authors will select professionals carrying them out and randomly select an identical number of professionals not doing these activities. In the centres where no CA is implemented, three professionals will be randomly selected. The selected professionals will complete the questionnaires for individual-level variables. Information about the registered population and the PCTs will be collected through questionnaires and secondary sources. Outcomes Variables will be collected from the community, the PCTs, the individual professionals and CAs. Analysis A descriptive analysis of all the variables will be carried out, along with a bivariate and a logistic regression analysis, with CAs being the primary outcome. Ethics and dissemination This study has been approved by the Research Ethics Committee of the Jordi Gol y Gurina Foundation in Barcelona and area 11 in Madrid. The questionnaire distributed to the professionals will be anonymous.

Factors related to the development of health-promoting community activities in Spanish primary healthcare: two case-control studies.

Objective Spanish primary healthcare teams have the responsibility of performing health-promoting community activities (CAs), although such activities are not widespread. Our aim was to identify the factors related to participation in those activities. Design Two case–control studies. Setting Performed in primary care of five Spanish regions. Subjects In the first study, cases were teams that performed health-promoting CAs and controls were those that did not. In the second study (on case teams from the first study), cases were professionals who developed these activities and controls were those who did not. Main outcome measures Team, professional and community characteristics collected through questionnaires (team managers/professionals) and from secondary sources. Results The first study examined 203 teams (103 cases, 100 controls). Adjusted factors associated with performing CAs were percentage of nurses (OR 1.07, 95% CI 1.01 to 1.14), community socioeconomic status (higher vs lower OR 2.16, 95% CI 1.18 to 3.95) and performing undergraduate training (OR 0.44, 95% CI 0.21 to 0.93). In the second study, 597 professionals responded (254 cases, 343 controls). Adjusted factors were professional classification (physicians do fewer activities than nurses and social workers do more), training in CAs (OR 1.9, 95% CI 1.2 to 3.1), team support (OR 2.9, 95% CI 1.5 to 5.7), seniority (OR 1.06, 95% CI 1.03 to 1.09), nursing tutor (OR 2.0, 95% CI 1.1 to 3.5), motivation (OR 3.7, 95% CI 1.8 to 7.5), collaboration with non-governmental organisations (OR 1.9, 95% CI 1.2 to 3.1) and participation in neighbourhood activities (OR 3.1, 95% CI 1.9 to 5.1). Conclusions Professional personal characteristics, such as social sensitivity, profession, to feel team support or motivation, have influence in performing health-promoting CAs. In contrast to the opinion expressed by many professionals, workload is not related to performance of health-promoting CAs.